THORACIC ANAESTHESIA
Bronchoscopic insertion
of double lumen
endotracheal tubes and
bronchial blockers
Nicholas Heseltine
Andrew Knowles
Abstract
Double-lumen tubes (DLTs) should be placed using a fibreoptic bron-
choscope. This allows correct positioning of the bronchial lumen in the
chosen mainstem bronchus. It also ensures that the blue bronchial
cuff does not obstruct the side to be ventilated when it is inflated
under direct vision. Fibreoptic bronchoscopy facilitates correct posi-
tioning of the ventilatory side slot of a right DLT over the right upper
lobe bronchus. The anaesthetist must know the fibreoptic tracheo-
bronchial anatomy to properly position left- and right-sided DLTs
and should always reconfirm the position of a DLT with fibreoptic
bronchoscopy after repositioning the patient. Maintaining orientation
(anterioreposterior) during fibreoptic bronchoscopy is crucial to posi-
tioning a DLT, particularly after the patient has been turned to the
lateral position. A fibreoptic bronchoscope can also be used as a
guide to direct a DLT under direct vision into its correct position.
Keywords Bronchial blocker; double lumen tube; fibreoptic bron-
choscopy; one lung ventilation; vivaSight
Royal College of Anaesthetics CPD Matrix: 2A01, 3A01, 3G00
Background
Double lumen endotracheal tubes (DLTs) allow the anaesthetist
to isolate the airways of the left and right lungs. Lung isolation
may be used to prevent contralateral lung contamination during
bronchial lavage as in pulmonary haemorrhage and infection or
in case of bronchial disruption. Differential lung ventilation
strategies may be employed via a DLT in thoracic surgery to
access the lungs, aorta and spinal cord, in minimally invasive
cardiac surgery and in upper gastrointestinal/oesophageal
surgery.
Carlens introduced the first DLTs for bronchorespirometry in
the 1940s. Since then there have been numerous design im-
provements to reduce misplacement. Despite this, until the
advent of routine fibreoptic bronchoscopy, incorrect positioning
Nicholas Heseltine MB ChB MRes is an Anaesthetic Trainee at
Blackpool Victoria Hospital, Blackpool, UK. Conflicts of interest: none
declared.
Andrew Knowles FRCA is a Consultant Cardiothoracic Anaesthetist
at Lancashire Cardiac Centre, Blackpool, UK. Conflicts of interest:
none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 22:3
Learning objectives
After reading this article, you should be able to:
C describe the anatomical difference between the right and left
main bronchi
C
C
explain the differences between left and right DLTs
demonstrate safe placement of DLTs and BBs
C recall the key fibreoptic views required to confirm correct
positioning of DLTs
C describe the advantages and disadvantages between DLTs and
BBs
C outline some common problems encountered while siting DLTs
and the appropriate action to take
of DLTs was commonplace and associated with significant
morbidity and mortality. Therefore familiarity with broncho-
scopic views and corresponding anatomy is essential for safe
DLT placement.
Bronchial blockers (BBs), using a single lumen endotracheal
tube (SLT), were introduced in 1982 as an alternative means of
lung isolation. They require a fibreoptic bronchoscope (FOB) for
placement and can be more technically difficult to place.
Therefore as for DLTs good anatomical knowledge and a degree
of FOB dexterity is required for safe placement.
Anatomy
The trachea averages 12 cm (range 10e13 cm) long in an adult
male, being slightly shorter in females. At its termination it bi-
furcates to form the right and left main bronchi. The right main
bronchus is shorter (approximately 2 cm), steeper and of larger
caliber than the left main bronchus. The right upper lobe bron-
chus (RUB) divides first and the right bronchus continues as the
bronchus intermedius for a further 2e3 cm before splitting into
the right middle and lower bronchi.
The left main bronchus projects more in the horizontal plane,
is approximately 5 cm in males, is narrower and divides into the
left upper and lower bronchi.
Multiple anatomical variants exist; a common example being
a tracheal RUB. Although characteristically picked up on pre-
operative computed tomography (CT), endoscopic conforma-
tion of the right upper lobe location is still important when
placing a DLT.
DLT design
Most modern DLTs are based on the Robertshaw design of two
D-shaped endotracheal tubes bonded together. These lumens are
fixed together on their flat sides to maintain a circular external
surface. The bronchial lumen has blue markings and the tracheal
is white. Both end lumens have cuffs proximal to their ventila-
tion ports. They are single use only, made of polyvinyl chloride
and without a carinal hook.
Unlike other breathing tubes they are sized by their external
diameter rather than internal diameter. Their internal diameter is
in fact much smaller and so requires a narrow FOB (<4 mm)
during placement.
142 Ó 2021 Published by Elsevier Ltd.
 THORACIC ANAESTHESIA

Selecting the correct size of DLT
Frequently 35e37 French (Fr) gauge is used for females and 39
e41 Fr for males. In women less 5 ft 3 in (160 cm) the author uses
32 Fr, 35 Fr up to 5 ft 7 in (67 cm) and 37 Fr above this height. In
men below 5 ft (165 cm), a 35 Fr is used, a 37 Fr up to 5 ft 8 in
(172 cm), a 39 Fr up to 6 ft (182 cm) and a 41 Fr above this
height. This can be adjusted with clinical examination for
particularly long or short necks. For paediatric use a 28 Fr is
available.1 Preoperative estimation of size can be done by mea-
surement of the tracheal and bronchial diameters on available
imaging. However the most reliable assessment is to insert and
visualize the ‘fit’ with a FOB.
The correct size DLT ultimately fulfills the following criteria:

It passes through the larynx and trachea with minimal
resistance.

It achieves one lung ventilation (OLV) with low bronchial
cuff volumes (<3 cm).

The bronchial lumen must not encroach on the lobar
bronchi.

The bronchial cuff must not herniate into the trachea.
Left DLTs
Left DLTs are more commonly used than right DLTs for both left-
and right-sided surgery. This is because right DLTs are more
difficult to position correctly due to the proximity of the RUB to
the carina. Also left DLTs reliably permit either left or right OLV.2
A left DLT is contraindicated when its bronchial lumen is
likely to interfere with surgery. This occurs when the staple line
crosses the left main bronchus during a left pneumonectomy or
in the presence of proximal intra-luminal pathology.
Insertion of a left DLT
Intubation of the trachea is performed with the DLT mounted on
an introducer and the bronchial lumen orientated anteriorly. This

Technique for left DLT insertion

Tracheal intubation Minimal or no resistance

Remove introducer, rotate DLT

anticlockwise and advance to Length (cm) = (height (cm)/10) + 12
resistance

Y-connector

Auscultate, inspect and note EtCO2

Cuff volume should not exceed 3ml.

Clamp tracheal lumen and
Auscultate and inspect to

Unclamp tracheal lumen then

clamp the bronchial lumen contralateral lung isolation

Unclamp bronchial lumen

Perform FOB via tracheal lumen 1. Termination of the tracheal

lumen must be proximal to
the carina
2. Bronchial cuff is seen in the
left main bronchus with no
herniation
3. Position of the RUL is
Position patient, recheck DLT
site and then secure main bronchus

Figure 1

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 THORACIC ANAESTHESIA
Figure 2
can be via direct laryngoscopy, videolaryngoscopy or guided by a
FOB. Although an awake intubation over a FOB is possible, in
practice it is less well tolerated due to the size of the DLT.
After the trachea is intubated the introducer is removed. The
DLT is advanced and simultaneously rotated anticlockwise to-
ward the left main bronchus. The following equation can be used
to predict the length required:
(Height (cm)/10) þ12 ¼ Insertion length at teeth (cm)
Therefore for a 170 cm adult the insertion length is approxi-
mately 29 cm.
Once the bronchus is intubated the tracheal cuff is inflated.
Auscultation, inspection and observation of the end tidal carbon
dioxide trace confirm bilateral ventilation.
Figure 3 A DLT in the left main bronchus with its cuff; not herniating
into the trachea.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 22:3
The position of the DLT and the adequacy of OLV is assessed
by endoscopic and clinical examination. These can be performed
simultaneously or sequentially. This article describes a simulta-
neous technique.
First the bronchoscope is passed through the tracheal lumen of
the DLT. The carina is observed with the tube passing into the left
main bronchus with the bronchial cuff deflated but visible. Next the
cuff is inflated with 1 ml of air at a time under vision. The cuff should
still be visible, not herniate into the trachea and have a volume less
than 3 ml. The right bronchial tree is now examined, noting the RUB
with its three segmental bronchi (apical, posterior and anterior).
This unique feature acts as an anatomical landmark and confirms
the observed anatomy. Now the FOB is passed through the bron-
chial lumen of the DLT to view the left upper and lower bronchi. The
tip of the bronchial lumen should not encroach upon these struc-
tures3 (Figures 1e3).
Following FOB examination the tracheal and bronchial lu-
mens are sequentially clamped and released enabling clinical
confirmation of OLV.
Right DLTs
Right DLTs are used less frequently because of difficulty in siting
them and their propensity to block the RUB. However, they are
still indicated when the left main bronchus needs to remain clear
as when the staple line is crosses the left main bronchus
(pneumonectomy and lung transplant) or in the presence of
proximal intra-luminal pathology. An important contraindication
is a tracheal bronchus, where if one were sited only the right
middle and lower lobes would be ventilated.
The right DLT differs from the left in having, an extra venti-
lation port and an oblique shaped cuff (Figure 4). These modi-
fications facilitate positioning without obstructing the RUB.
144 Ó 2021 Published by Elsevier Ltd.
 THORACIC ANAESTHESIA
Figure 4 A right DLT with its extra ventilatory side port.
Insertion of a right DLT
The insertion technique right DLTs is as for left-sided tubes
except that the DLT must be rotated clockwise toward the right
main bronchus and the extra ventilatory port aligned with the
orifice of the RUB.
After siting the right DLT the FOB is passed down the tracheal
lumen. The carina should be seen with the blue bronchial cuff in
the right main bronchus. It is then inflated under vision to ensure
the cuff does not herniate into the trachea. The FOB is then
passed through the bronchial lumen and through the end port
into the bronchus intermedius. After viewing the right lower and
middle bronchi the scope is withdrawn slowly into the DLT until
the blue colour around the bronchial cuff is seen. The tip of the
FOB is then anteverted to observe the extra ventilation port. If the
DLT is in the correct position the RUB should be seen through
this. If it is not observed then the DLT is manipulated to bring it
into view. A trained assistant must deflate the bronchial and
tracheal cuffs then the DLT is rotated, usually the orifice of the
Figure 5
ANAESTHESIA AND INTENSIVE CARE MEDICINE 22:3
RUB is in the 3 o’clock position. If this manoeuvre does not bring
the RUB into view the whole DLT is slowly withdrawn while
being rotated until it is in view. After positioning the patient
bronchoscopy is repeated to check the DLT has not moved
(Figure 5).
Endoscopic-guided bronchial intubation
Alternatively, after tracheal intubation the FOB can be passed
through the bronchial lumen of the DLT and used to guide
the tube into position. This has the advantages of reduced
failure rate and also allows for simultaneous assessment of
tracheal and bronchial anatomy. Disadvantages are that it
may increase apnoea time and requires a two-handed
technique.
VivaSight-DL
The VivaSight-DL is a left DLT incorporating a fibreoptic scope at
the end of its tracheal lumen. It has an extra port to clean se-
cretions from the fibreoptic tip but is otherwise based on the
Robertshaw design. It can reduce intubation and correct place-
ment times, is only available as a left-sided tube and is dispos-
able (Figures 6 and 7).
A concern in use is that since its camera is fixed a flexible FOB
may sometimes be needed to confirm its placement thereby
adding to cost. However, research suggests the requirement for
another bronchoscope with the VivaSight-DL is infrequent and
thereby enhancing its cost effectiveness.4
Troubleshooting a DLT
Common problems encountered and possible solutions are
detailed in Table 1.
Bronchial blockers
Bronchial blockers vary in design however can be summarized as
flexible narrow gauge cuffed devices (Figure 8). They are used
145 Ó 2021 Published by Elsevier Ltd.
 THORACIC ANAESTHESIA

Figure 6 VivaSight-DL. Camera between tracheal and bronchial cuffs.

Figure 8 Left DLT and Uniblocker.

nasal and tracheostomies), in difficult airways and rapid

Figure 7 VivaSight in situ view with integrated camera and screen.
with a specific mount and a normal single lumen tube. The
cuffed end requires placement under vision of a FOB prior to cuff
inflation and lung isolation.
There are multiple designs in common practice, each with
specific features (see Table 2).
Bronchial blockers versus double lumen tubes
The key advantage of BBs is that they can be used with SLTs.
This means they can be used in patients already intubated (oral,
sequence inductions. The use of an SLT also reduces laryngeal
and tracheal trauma. Furthermore, because they are smaller and
more flexible than DLTs they can be used in patients with
deformed anatomy and can block individual lobes (Table 3).
However, they have some disadvantages related to their
narrow lumens and flexibility. Because of their narrow lumens,
suction, oxygen insufflation and CPAP are less effective or not
achievable. As a result, management of hypoxia during OLV
can be more difficult. Equally, once the lung is blocked its
collapse takes more time and because of greater flexibility BBs
are more prone to displacement. Likewise BBs, except for the
EZ blocker, unless repositioned, cannot be used when alter-
nating side of ventilation is required (e.g. thoracic
sympathectomy).

Troubleshooting DLTs
Problem Underlying cause Possible solution

Resistance on passing DLT
High bronchial cuff volume or persistent
bronchial cuff leak
One-lung ventilation not achieved
One-lung ventilation prior to lumen clamping
C Too large DLT C Re-attempt with smaller DLT
C Tracheal or laryngeal pathology C Visualize the larynx with
videolaryngoscope
C Visualize trachea and bronchus with bron-
choscope during bronchial intubation
C Too small DLT C Check position with bronchoscope
C Incorrect placement C If position correct consider siting a larger
DLT
C Misplacement C Perform bronchoscopy to check DLT posi-
C Aberrant anatomy tion and assess for anatomical variants
C Bronchus intubated with bronchial and C Withdraw DLT until bilateral ventilation
tracheal lumens occurs

Table 1

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 THORACIC ANAESTHESIA

Common bronchial blocker types

Bronchial blocker Design features

Arndt BB is mounted on a guide wire with a distal

loop to snare the FOB and so aid its
placement. It has a 1.4 mm lumen
Cohen The tip is anteverted or retroverted with a
proximal wheel
EZ blocker The tip is Y shaped to cover the carina. Both
arms are cuffed to enable blocking of either
bronchus without repositioning
Uniblocker (Univent) A semi-rigid BB with a curved end to aid
placement. Its predecessor the Univent, a SLT,
incorporated this BB

Table 2
Advantages and disadvantages of bronchial blockers
Advantages
C Allows for SLT

easier rapid sequence
intubation

less laryngeal and
tracheal trauma

less tracheal cuff
rupture
C Can be used with tra-
cheostomy or nasal SLT
C Lobe or segmental
isolation
C Can be used with
abnormal anatomy
Disadvantages
C Less effective suction
C Needs bronchoscopy
C More difficult to manage
hypoxia
C Unable to perform bron-
choscopy past BB once
inflated
C Unable to do alternate
OLV without
repositioning
C More easily displaced
Figure 9 The Univent bronchial blocker is deflated and visible in the
left main bronchus.
Tracheal bronchus
A tracheal RUB is a relatively common variant (0.1e2%) offering
a unique DLT challenge. Management depends on which lung is
to be deflated. If the left lung is to be deflated and the right
ventilated then placing a single lumen tube above the aberrant
bronchus and inserting a bronchial blocker in the left main
bronchus is the best option. If the right lung is to be deflated and
the left ventilated then placing a left-sided DLT will normally
suffice. However, if the right lung does not deflate adequately
then another option is to use a Univent tube with an extra
bronchial blocking device. Consequently two bronchial blockers
may be employed to occlude separately; the right main bronchus
and tracheal RUB. A

Table 3
Insertion of a BB (Figure 9)
First tracheal intubation is performed, ideally using a larger SLT
(8.5/9) to allow for easy passage of the BB. Then the BB mount is
connected and ventilation is resumed prior to passing it.
Depending on the type of BB differing techniques are used. The
Arndt is snared onto the tip of the scope and guided into position.
Other types are semi-rigid so are guided under FOB vision. Once
in position the cuff is inflated ensuring there is no balloon
herniation.
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ANAESTHESIA AND INTENSIVE CARE MEDICINE 22:3 147 Ó 2021 Published by Elsevier Ltd.